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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENELL/PUMP PERMIT <br /> NON-REFUNDABLE PERMIT 1568 EAST HAZELTON AVENUE-$TOCKTON CA 95205 - (209)468-3420 <br /> rte' CALL 209 953-7697 FOR INSPECTIONS <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB,ADDRESS 19C <br /> CITY/ZIP�/✓/,?G/J� L�i4 gfZ 2 7 <br /> CROSS STREET_ � /C�/rJ s Qom/ APN G _ / k D <br /> PARCEL SIZE �� V LAND USE APPLICATION# 0 <br /> OWNER NAME �_ A <br /> _ PHONE Cn <br /> OWNER ADDRESS ne <br /> CITY/STATE/ZIPL�j lj ✓2 y0 <br /> CONTRACTOR A 3 A71 <br /> PHONE_ 77Z - a-76-7 <br /> CONTRACTOR ADDRESS QQ /_,�!Z 9 CITY/STATE/ZIP <br /> _!_ 11--V SDn <br /> �� �s 4i z�Jsas <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �4C-57 0C-61 ❑D-09 L]Other NUMBER lelAP7e EXPIRATIONDATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Xbomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring [-]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: a er ys em ame Uunlact Name or 11none um er <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification <br /> O Other <br /> Monitoring Wells #of wells #of borings #of borings <br /> — 9 ( ) El Boring(s) []Geotechnical <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum E]Pump Re lacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method yXMud Rotary E]Air Rotary ❑Auger ❑Cable Tool L]Push Point ❑ Other <br /> Proposed Well Depth 320 ft Excavation ZL/y in diameter E]Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter (;, in Thickness/Gauge/ASTM Sched 0k 2/ ❑Steel Plastic [I Stainless Steel E]Other <br /> 12 <br /> Grout Seal Depth /,0 _ft =Neat Cement(94 Ib bag/5-10 gal water) [-]Sand Cement /,01' sack mix/7 gal water <br /> ❑Bentonite(20%solid _ er <br /> Grout Placement Method xPumped _::-_- Fa, ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTt_ Installed By XDriller =Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP V_Subme-�;,denTurt-e --Other HP,'57 Pump Set_ZeZQ_ft Standing Water Level 'e ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> -E <br /> MINIM4 OUR ADNOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ��Y/ DATE ��- Zd 1� <br /> —————— —— — —— ---————————— <br /> A UI <br /> T <br /> T/ E <br /> DEPARTMENT USE ONLY <br /> < f <br /> Application Accepted By Date -e l <br /> 1 1 t ` f/ Area _ Employee ID#� <br /> Grout Inspection By Date (j—f—2oy ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS A/U <br /> PE SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Request# <br /> _Z1 Cc <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8101/16 <br />